What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?
Establish rapport and develop treatment goals.
Acknowledge the client's actions, and generate alternative behaviors.
Explore how thoughts and feeling about this client may adversely impact nursing care.
Attempt to find alternative placement.
The Correct Answer is A
a. Establish rapport and develop treatment goals: During the orientation phase, the primary focus is on building trust and rapport with the client. Establishing rapport and developing treatment goals are essential to creating a therapeutic alliance and setting the stage for effective treatment.
b. Acknowledge the client's actions, and generate alternative behaviours: This action is more appropriate during the working phase, where the nurse and client work on behavior change and coping strategies.
c. Explore how thoughts and feelings about this client may adversely impact nursing care: This is part of the nurse's self-reflection and supervision but is not the priority during the orientation phase.
d. Attempt to find alternative placement: This may be considered if the current setting is unsuitable, but it is not the primary focus of the orientation phase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. "Why are you concerned about these types of questions?"
This response can seem confrontational and might increase the client's defensiveness.
b. "We can skip these questions, if you like. It isn't imperative that we complete this section."
Skipping the questions can lead to an incomplete assessment, and it does not address the client's concern.
c. "It is just a routine part of our assessment. All clients are asked these same questions."
While this is true, it does not explain the importance of the questions and may seem dismissive.
d. "Psychological factors like excessive stress have been found to affect medical conditions."
This response explains the rationale behind the questions and how they relate to the client's overall health, potentially helping the client understand the importance of a holistic assessment.
Correct Answer is D
Explanation
a. Akathisia and hypersalivation. These side effects are uncomfortable but generally not immediately life-threatening.
b. Dry mouth and urinary retention. These side effects are concerning and should be monitored, but they do not typically require immediate intervention unless severe.
c. Akinesia and insomnia. While akinesia (lack of movement) and insomnia are significant, they are not immediately life-threatening symptoms.
d. Sore throat, fever, and malaise. This choice is correct because these symptoms could indicate agranulocytosis, a potentially life-threatening side effect of clozapine that requires immediate medical intervention.
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